AUDIT REPORT 

Audit of NRC’s Occupant Emergency 

Program 

OIG-09-A-07 February 11, 2009 

All publicly available OIG reports (including this report) are accessible through 

NRC’s Web site at: 

http:/www.nrc.gov/reading-rm/doc-collections/insp-gen/ 
UNITED STATES 

NUCLEAR REGULATORY COMMISSION 

WASHINGTON, D.C. 20555-0001 

OFFICE OF THE 

INSPECTOR GENERAL 

 February 11, 2009 

MEMORANDUM TO: R. William Borchardt 

Executive Director for Operations 

FROM: Stephen D. Dingbaum /RA/ 

 Assistant Inspector General for Audits 

SUBJECT: AUDIT OF NRC’S OCCUPANT EMERGENCY PROGRAM 

(OIG-09-A-07) 

Attached is the Office of the Inspector General’s (OIG) audit report titled, Audit of NRC’s 

Occupant Emergency Program.

The report presents the results of the subject audit. Agency management comments 

provided after the January 26, 2009, exit conference have been incorporated into this 

report. 

Please provide information on actions taken or planned on each of the 

recommendations within 30 days of the date of this memorandum. Actions taken or 

planned are subject to OIG follow up as stated in Management Directive 6.1. 

We appreciate the cooperation extended to us by members of your staff during the 

audit. If you have any questions or comments about our report, please contact me at 

415-5915 or Beth Serepca, Team Leader, Security and Information Management Audit 

Team, at 415-5911. 

Attachment: As stated 
Electronic Distribution

Edward M. Hackett, Executive Director, Advisory Committee on Reactor 

 Safeguards 

E. Roy Hawkens, Chief Administrative Judge, Atomic Safety and 

 Licensing Board Panel 

Karen D. Cyr, General Counsel 

John F. Cordes, Jr., Director, Office of Commission Appellate Adjudication 

Jim E. Dyer, Chief Financial Officer 

Margaret M. Doane, Director, Office of International Programs 

Rebecca L. Schmidt, Director, Office of Congressional Affairs 

Eliot B. Brenner, Director, Office of Public Affairs 

Annette Vietti-Cook, Secretary of the Commission 

R. William Borchardt, Executive Director for Operations 

Bruce S. Mallett, Deputy Executive Director for Reactor 

 and Preparedness Programs, OEDO 

Martin J. Virgilio, Deputy Executive Director for Materials, Waste, Research, 

 State, Tribal, and Compliance Programs, OEDO 

Darren B. Ash, Deputy Executive Director for Corporate Management 

 and Chief Information Officer, OEDO 

Vonna L. Ordaz, Assistant for Operations, OEDO 

Timothy F. Hagan, Director, Office of Administration 

Cynthia A. Carpenter, Director, Office of Enforcement 

Charles L. Miller, Director, Office of Federal and State Materials 

 and Environmental Management Programs 

Guy P. Caputo, Director, Office of Investigations 

Thomas M. Boyce, Director, Office of Information Services 

James F. McDermott, Director, Office of Human Resources 

Michael R. Johnson, Director, Office of New Reactors 

Michael F. Weber, Director, Office of Nuclear Material Safety and Safeguards 

Eric J. Leeds, Director, Office of Nuclear Reactor Regulation 

Brian W. Sheron, Director, Office of Nuclear Regulatory Research 

Corenthis B. Kelley, Director, Office of Small Business and Civil Rights 

Roy P. Zimmerman, Director, Office of Nuclear Security and Incident Response 

Samuel J. Collins, Regional Administrator, Region I 

Luis A. Reyes, Regional Administrator, Region II 

James L. Caldwell, Regional Administrator, Region III 

Elmo E. Collins, Jr., Regional Administrator, Region IV 

 
Audit of NRC’s Occupant Emergency Program 

i

EXECUTIVE SUMMARY 

BACKGROUND

An Occupant Emergency Program (OEP) is defined as, “...a short-term 

emergency response program [that] establishes procedures for 

safeguarding lives and property during emergencies....” Effective OEPs 

include an overview of the roles and responsibilities of involved parties, 

address a wide range of hazards and threats, involve coordination with 

local emergency responders, and consider safety codes and regulations. 

An occupant emergency plan is a fundamental part of an OEP. An 

occupant emergency plan contains a set of procedures to protect life and 

property in a specific Federally occupied space under defined emergency 

conditions. Federal Management Regulations require every facility owned 

or leased by the Federal Government to have an occupant emergency 

plan. These regulations contain detailed information on how an occupant 

emergency plan should be developed and implemented. 

In accordance with the regulations, the Nuclear Regulatory Commission 

(NRC) issued Management Directive 10.130, Safety and Health Program 

Under the Occupational Safety and Health Act. This directive provides 

criteria for developing and implementing individualized occupant 

emergency plans for each of the NRC-owned or leased buildings. 

Responsibility for the development, implementation, and maintenance of 

NRC’s OEP is shared between the Office of Administration and Office of 

Human Resources. Together, both offices have an overall responsibility 

for familiarizing agency staff with the agency OEP so that proper 

procedures are followed during an emergency, thereby minimizing risk to 

NRC staff and property. 

PURPOSE

The audit objective was to evaluate the extent to which the agency’s 

Occupant Emergency Program complies with Federal regulations and 

standards. 
Audit of NRC’s Occupant Emergency Program 

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RESULTS IN BRIEF

Although NRC’s Occupant Emergency Program meets Federal 

requirements and standards, weaknesses pertaining to the 

implementation of the agency’s Occupant Emergency Program were 

identified. Specifically, 

• Staff lack awareness of emergency procedures. 

• Emergency equipment is inadequate and poorly maintained. 

• Signage in the White Flint complex is inadequate and inconsistent. 

Staff Lack Awareness of Emergency Procedures 

NRC has not adequately prepared its employees for emergencies, thereby 

potentially endangering staff safety and well-being. A recent Office of the 

Inspector General survey found that many NRC staff were unaware of 

what to do in an emergency. For example, approximately one-third of 

employees surveyed had not read their building’s occupant emergency 

plan and did not know the location of their designated assembly area or 

who to report to upon arrival at the designated spot. In addition, more 

than one-third of surveyed employees who have assigned duties during an 

emergency (e.g., floor monitors, stairwell monitors) had not been trained 

on those duties. Staff are unfamiliar with procedures and untrained on 

duties because NRC has not provided staff with training on emergency 

procedures or conducted full-scale, annual evacuation drills. As a result, 

NRC staff and other building occupants may not know how to respond 

appropriately during an emergency, thereby putting their safety and that of 

their colleagues at risk. 

Emergency Equipment Is Inadequate and Poorly Maintained 

Federal agencies have published guidelines governing the placement and 

maintenance of lifesaving equipment such as Automatic External 

Defibrillators (AEDs) and Personal Emergency Kits (PEKs) for staff use 

during an emergency. NRC’s AED program is inadequate, and agency 

PEKs are inconsistently provided and maintained. Some of the agency’s 

AEDs and PEKs may not be adequate because the agency does not 

require that such equipment be routinely maintained. Without conducting 

routine maintenance or consistently issuing emergency equipment, NRC 

lacks assurance that lifesaving emergency equipment will be available and 

ready to use when needed. 
Audit of NRC’s Occupant Emergency Program 

iii

Signage in the White Flint Complex Is Inadequate and Inconsistent

While the agency has posted signage denoting exit routes, some of the 

signage does not meet Federal guidelines and industry standards. 

Specifically, current signage, including evacuation maps and stairwell 

routing in the White Flint complex, is inadequate and inconsistently 

designed and posted. These deficiencies exist because management was 

unfamiliar with applicable guidance and standards. Without upgrading 

existing signage to meet Federal guidance and industry standards, NRC 

staff in the White Flint complex may be unable to evacuate the complex 

safely and expediently during an emergency. 

RECOMMENDATIONS

This report makes recommendations to improve the agency’s 

implementation of its Occupant Emergency Program. A consolidated list 

of these recommendations appears in Section IV of this report.

AGENCY COMMENTS

At the exit conference on January 26, 2009, agency management stated 

their agreement with the findings and recommendations in this report. 

However, management also wanted to provide written comments to 

provide further insight into the actions the agency is taking to improve the 

Occupant Emergency Program. Specifically, management wished to 

include agency actions that resulted from a lessons learned report 

pertaining to a June 25, 2008, medical event. The agency’s comments 

are provided in Appendix B of this report. 
Audit of NRC’s Occupant Emergency Program 

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Audit of NRC’s Occupant Emergency Program 

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ABBREVIATIONS AND ACRONYMS 

AED Automatic External Defibrillator 

NRC Nuclear Regulatory Commission 

OEP Occupant Emergency Program 

OIG Office of the Inspector General 

PEK Personal Emergency Kit 
Audit of NRC’s Occupant Emergency Program 

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Audit of NRC’s Occupant Emergency Program 

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TABLE OF CONTENTS 

EXECUTIVE SUMMARY ............................................................. i 

ABBREVIATIONS AND ACRONYMS......................................... v 

 

I. BACKGROUND..................................................................... 1 

II. PURPOSE............................................................................. 2 

III. FINDINGS ............................................................................ 3 

A. STAFF LACK AWARENESS OF EMERGENCY 

 PROCEDURES.................................................................. 3 

B. EMERGENCY EQUIPMENT INADEQUATE AND POORLY 

 MAINTAINED .................................................................... 8 

C. SIGNAGE IN WHITE FLINT COMPLEX INADEQUATE AND 

 INCONSISTENT ............................................................... 13 

IV. CONSOLIDATED LIST OF RECOMMENDATIONS............ 17 

V. AGENCY COMMENTS ....................................................... 18 

APPENDICES

A. SCOPE AND METHODOLOGY .......................................... 20 

B. AGENCY COMMENTS ....................................................... 22 
Audit of NRC’s Occupant Emergency Program 

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Audit of NRC’s Occupant Emergency Program 

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I. BACKGROUND

An Occupant Emergency Program (OEP) is defined as, “...a short-term 

emergency response program [that] establishes procedures for 

safeguarding lives and property during emergencies....” Effective OEPs 

include an overview of the roles and responsibilities of involved parties, 

address a wide range of hazards and threats, involve coordination with 

local emergency responders, and consider safety codes and regulations. 

Federal Management Regulations require every facility owned or leased 

by the Federal Government to have an occupant emergency plan. In 

accordance with the regulations, the Nuclear Regulatory Commission 

(NRC) issued Management Directive 10.130, Safety and Health Program 

Under the Occupational Safety and Health Act. This directive provides 

criteria for developing and implementing occupant emergency plans for 

NRC-owned or leased buildings.1

 An occupant emergency plan is a 

fundamental part of an OEP. An occupant emergency plan contains a set 

of procedures to protect life and property in a specific Federally occupied 

space under defined emergency conditions. 

Responsibility for the development, implementation, and maintenance of 

NRC’s OEP is shared between the Office of Administration and Office of 

Human Resources. Specifically, the Office of Administration has 

responsibility for the following OEP-related activities: (1) developing and 

implementing the agency’s occupant emergency plan and assisting the 

regional offices in developing their own occupant emergency plans; (2) 

providing emergency preparedness training to headquarters staff, 

including the scheduling and execution of fire drills; (3) ensuring that 

necessary resources are available to respond to emergencies in 

accordance with the occupant emergency plans; and (4) coordinating and 

obtaining approval for significant changes to the agency’s occupant 

emergency plan. The Office of Human Resources has responsibility for 

assigning its personnel to perform staff accountability functions2

 during 

emergencies requiring evacuation of the headquarters buildings. 

Together, both offices have an overall responsibility for familiarizing 

agency staff with the agency OEP so that proper procedures are followed 

during an emergency, thereby minimizing risk to NRC staff or property. 

 

1 Management Directive 10.130 refers to occupant emergency plans as emergency protection plans. 2 “Accountability functions” refers to accountability activities performed by designated personnel from the Office of Human 

Resources who have responsibility for accounting for each employee from their assigned office during a full-evacuation drill. 
Audit of NRC’s Occupant Emergency Program 

2

NRC headquarters includes six buildings located throughout Rockville and 

the Bethesda areas of Maryland, including the One and Two White Flint 

high-rises (White Flint complex) as well as the Church Street, Twinbrook, 

Executive Boulevard, and Gateway office buildings. Most headquarters 

staff work in the White Flint complex.3

 Each building has its own unique 

occupant emergency plan with details specific to its location and facility. 

II. PURPOSE 

The audit objective was to evaluate the extent to which the agency’s 

Occupant Emergency Program complies with Federal regulations and 

standards. Appendix A contains information on the audit scope and 

methodology. 

 

3 Approximately 2,800 staff are stationed at the White Flint complex.
Audit of NRC’s Occupant Emergency Program 

3

III. FINDINGS 

By having an Occupant Emergency Program and also an occupant 

emergency plan for every building, NRC generally complies with Federal 

regulations. However, the Office of the Inspector General (OIG) identified 

opportunities for improvement. Specifically: 

A. Staff lack awareness of emergency procedures. 

B. Emergency equipment is inadequate and poorly maintained. 

C. Signage in White Flint complex is inadequate and inconsistent. 

Addressing these issues will strengthen the agency’s OEP. 

A. Staff Lack Awareness of Emergency Procedures 

NRC has not adequately prepared its employees for emergencies, thereby 

potentially endangering staff safety and well-being. A recent OIG survey 

found that many NRC staff were unaware of what to do in an emergency. 

For example, approximately one-third of employees surveyed had not 

read their building’s occupant emergency plan and did not know the 

location of their designated assembly area or who to report to upon arrival 

at the designated spot. In addition, more than one-third of surveyed 

employees who have assigned duties during an emergency (e.g., floor 

monitors, stairwell monitors) had not been trained on those duties. Staff 

are unfamiliar with procedures and untrained on duties because NRC has 

not provided staff with training on emergency procedures or conducted 

full-scale, annual evacuation drills. As a result, NRC staff and other 

building occupants may not know how to respond appropriately during an 

emergency, thereby putting their safety and that of their colleagues at risk. 

Agency Occupant Emergency Plans

NRC headquarters occupant emergency plans state that agency 

management has responsibility for ensuring that building occupants are 

provided with and aware of their building’s occupant emergency plan. The 

plans state that training will be provided to all staff on their building’s 

emergency procedures, including specific training for those staff with 

assigned duties during an emergency, and that such training is imperative 

to ensure the maximum effectiveness of the occupant emergency plans. 

Recent tragedies, such as the September 11, 2001, terrorist attacks, 

underscore the importance of training staff in emergency procedures. A 

National Institute of Standards and Technology report examining staff 

emergency response during the collapse of the World Trade Center noted 
Audit of NRC’s Occupant Emergency Program 

4

that an effective means for training staff on emergency procedures is to 

conduct regular, full-scale evacuation drills. According to the report, such 

drills helped a significant number of personnel stationed in World Trade 

Center Tower Two survive the collapse of the building.4

 

Staff Awareness of Emergency Procedures Lacking 

OIG conducted a survey of 159 headquarters employees assigned to the 

six headquarters locations. The survey results, listed below, revealed that 

staff were unaware of emergency response procedures as described in 

the headquarters occupant emergency plans. 

• 34 percent had not read the occupant emergency plan for their facility. 

• 66 percent did not know the NRC emergency number. 

• 30 percent did not know the location of their designated assembly 

area. 

• 28 percent did not know who to report to upon reaching the designated 

assembly area. 

• 72 percent were not instructed on accountability procedures if there is 

an emergency at work and they are out of the office. 

 

4 Morgan Stanley Dean Witter, an investment firm, occupied 22 floors of Tower Two in the World Trade Center. As a result of the 

1993 terrorist attack on the World Trade Center, Morgan Stanley’s head of security organized frequent, surprise evacuation drills 

that required all personnel to immediately leave their desks and proceed two by two down the stairwells to a pre-designated floor. 

Each drill, which pulled the firm’s brokers off their phones and away from their computers, cost the company money. However, 

when the tower collapsed on September 11, 2001, only 13 Morgan Stanley employees were trapped, while 2,687 employees were 

able to evacuate safely.
Audit of NRC’s Occupant Emergency Program 

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Headquarters Occupant 

Emergency Plan Survey

0

10

20

30

40

50

60

70

80

Have not

read plan

Do not

know NRC

emergency

number

Do not

know

location of

assembly

area

Do not

know who

to report to

at

assembly

area

Do not

know outof-office

emergency

procedures

Percentage based on 

159 employees surveyed

Figure 1 - Results of survey regarding staff awareness of headquarters occupant emergency 

plans 

Additionally, 24 out of the 159 employees interviewed were assigned 

responsibilities during an emergency. Of those, 42 percent (10 

employees) indicated they had not been trained on their emergency 

duties. Although the agency routinely conducts fire drills as required by 

Federal regulations, these exercises are limited in scope and do not 

involve several key features of a full-scale evacuation such as mustering5

and accountability assessments.6

Lack of Management Emphasis 

Staff are unfamiliar with emergency procedures because the agency has 

not mandated that regular training be provided to staff or that annual fullscale evacuation drills are conducted at all headquarters buildings. 

 

5 Mustering refers to the assembly of employees in a pre-designated space. 

6

 The term “accountability assessment” refers to the act of physically accounting for all employees during a full-scale evacuation.
Audit of NRC’s Occupant Emergency Program 

6

 Training

NRC’s headquarters occupant emergency plans state that regular training 

is necessary to ensure the maximum effectiveness of the occupant 

emergency plans during an emergency. However, staff, including those 

with assigned responsibilities during an emergency, have not received 

periodic training on emergency procedures because there is no agency 

policy requiring that such training occur. Rather, it is left up to staff to 

familiarize themselves with emergency procedures, and any revisions 

thereof, noted in their building’s occupant emergency plan. 

 Full-Scale Evacuation Drills

Although the agency conducts regular fire drills,7 agency policy does not 

require annual full-scale evacuation drills, which include complete building 

evacuation, mustering, and staff accountability assessments. For 

example, the last full-scale evacuation drill was held in October 2004 – 

more than 4 years ago. Since the previous full-scale evacuation drill there 

have been several office moves, space reconfigurations, and 1,5888 new 

employees hired. This has resulted in a large percentage of staff being 

unfamiliar with emergency procedures. 

Safety of Agency Staff at Greater Risk 

Because the agency has not formalized a policy requiring that regular 

training be provided to staff and full-scale evacuation drills be held 

annually, staff may not know how to respond appropriately during an 

emergency. Regular training and practical experience as provided by a 

full-scale evacuation drill could help reduce the fear, panic, and mass 

confusion that could arise during an actual emergency evacuation. 

Without regular training and annual full-scale evacuation drills, the safety 

and well being of agency staff are put at greater risk. 

Recommendations

OIG recommends that the Executive Director for Operations: 

1. Require annual training for those with responsibilities, such as floor 

and stair monitors, during an emergency. 

 

7 “Regular fire drills” refers to those exercises in which an alarm is sounded and evacuation is limited to a three-floor area. These 

drills often involve relocating to another floor and not evacuating the building. 8 This figure was provided by the Office of Human Resources.
Audit of NRC’s Occupant Emergency Program 

7

2. Require annual, unannounced, full-scale evacuation drills, including 

mustering and accountability assessments, at all headquarters and 

regional complexes. 

3. Provide employees with periodic guidance reinforcing key points of the 

agency’s occupant emergency plans and emergency procedures. 
Audit of NRC’s Occupant Emergency Program 

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B. Emergency Equipment Inadequate and Poorly Maintained 

Federal agencies have published guidelines governing the placement and 

maintenance of lifesaving equipment such as Automatic External 

Defibrillators (AEDs) and Personal Emergency Kits (PEKs) for staff use 

during an emergency. NRC’s AED program is inadequate, and agency 

PEKs are inconsistently provided and maintained. Some of the agency’s 

AEDs and PEKs may not be adequate because the agency does not 

require that such equipment be routinely maintained. Without conducting 

routine maintenance or consistently issuing emergency equipment, NRC 

lacks assurance that lifesaving emergency equipment will be available and 

ready to use when needed. 

Federal Guidance 

In response to recent terrorist acts and catastrophic natural disasters, the 

Government has published guidelines pertaining to the placement and 

maintenance of lifesaving equipment and supplies in Federal buildings. 

Guidelines pertain to the placement and maintenance of AED devices in 

Federal buildings and recommend that Federal employees are supplied 

with PEKs. 

Automatic External Defibrillators

The Department of Health and Human Services issued the Federal 

Occupational Health Public Access Defibrillation Guidelines, which 

address the placement and maintenance of AEDs in Federal buildings. 

The Guidelines state that AEDs should be (1) routinely maintained and 

checked for operability, (2) placed near a telephone, and (3) referenced in 

the agency occupant emergency plan. Additionally, the agency issued 

Management Directive 10.122, Employee Assistance and Wellness 

Services Program, which states that the names of AED-trained employees 

located at the respective site should be posted near the AEDs. Lastly, 

industry best practice states that AEDs should be placed in areas where 

people may regularly gather. 

 

Personal Emergency Kits

The Federal Protective Service issued the Secure Facilities, Safe 

Occupants document which provides instructions on developing an 

effective PEK program. The guidance lists items that should be included 

in the kits and recommends how the kits should be maintained. For 
Audit of NRC’s Occupant Emergency Program 

9

example, the guidance recommends that these kits contain a mask, water, 

a flashlight and batteries, and a first aid kit. Additionally, the guidance 

stresses the importance of maintaining the kits so they are ready to use 

when needed. 

OIG Inspection 

Automatic External Defibrillators Program Weaknesses

Auditors inspected 40 AEDs located in the White Flint complex and 

Twinbrook, Executive Boulevard, and Gateway office buildings in addition 

to interviewing staff involved in the placement and maintenance of agency 

AEDs. Auditor’s found that the AEDs are not routinely maintained or 

checked for operability. Further, AEDs are not always placed in locations 

where people gather, e.g., the auditorium or parking garage levels. The 

inspection results, listed below, revealed that there are opportunities for 

improving agency management of AEDs. Figure 2 shows the inspection 

results. 

• 100 percent of AEDs do not have a telephone in the immediate vicinity. 

• 100 percent of AEDs do not have a contact list posted nearby. 

• 7.5 percent of AED cabinets have stickers indicating that the alarm 

batteries are not operational.9

 

Auditors also found that AEDs are not specifically referenced in the 

headquarters occupant emergency plans. 

 9 AED cabinets are equipped to sound an alarm when the cabinet is opened. Without batteries, however, the alarm will 

not sound. 
Audit of NRC’s Occupant Emergency Program 

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AED Inspection

0

10

20

30

40

50

No telephone

nearby

No contact list No batteries

Number of AED

s

Inspected (40)

 Figure 2 – Results of AED inspection 

Auditors also found during the AED inspection that two of the devices 

were marked as out-of-order for several weeks and no instructions were 

provided to locate alternative devices.10 

 

 

 Out-of-order defibrillator on P2 parking level of One White Flint 

 

10 The AEDs, located on P2 and P3 of One White Flint building, have since been repaired.
Audit of NRC’s Occupant Emergency Program 

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Personal Emergency Kit Weaknesses

Auditors inspected 139 NRC-supplied PEKs, and interviewed their 

respective owners to determine their familiarity with kit contents. Auditors 

identified two weaknesses related to the issuance and maintenance of the 

kits. Specifically, the PEKs are distributed inconsistently and some of the 

kit contents are outdated and possibly inadequate. 

The agency has not been consistent in issuing the kits to headquarters 

staff and has not actively maintained the kits by refreshing perishable 

items. OIG inspection results, listed below, revealed that there are 

opportunities for improving agency management of PEKs. 

 

• 86 percent contained expired water. 

• 75 percent did not contain a first aid emergency kit. 

• 88 percent contained flashlights with batteries that had never been 

replaced. 

Headquarters PEK Inspection

0

10

20

30

40

50

60

70

80

90

100

No PEK Expired Water No First Aid Kit No Battery

Replacement

Percentage (based on 139 PEKs)

 Figure 3-PEK inspection results 
Audit of NRC’s Occupant Emergency Program 

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During interviews with staff, OIG found that PEKs are not regularly 

provided to consultants or contractors. In fact, auditors noted that 17 

percent of staff interviewed did not have a PEK.11 

Lack of Policies and Procedures 

The agency AED and PEK programs are inadequate because agency 

management has not adequately maintained emergency equipment or 

taken into consideration industry best practices for emergency equipment. 

Staff Unprepared for Emergency 

Because the agency’s basic lifesaving equipment and emergency supplies 

are not adequately maintained or consistently issued, employees may be 

at risk during an emergency. 

Recommendations

OIG recommends that the Executive Director for Operations: 

4. Develop procedures for ensuring that AEDs are routinely maintained 

and checked for operability. 

5. Post contact information and, where necessary, a telephone in the 

immediate vicinity of all AED devices. 

6. Publicize the location of each AED (e.g., on the internal Web site or in 

the agency’s occupant emergency plan). 

7. Include information on the AED program in the agency’s occupant 

emergency plan. 

8. Develop procedures for consistently issuing PEKs. 

9. Develop procedures for properly maintaining PEKs. 

 

11 17 percent is based on our initial survey of 168 employees of which 29 did not have a PEK.
Audit of NRC’s Occupant Emergency Program 

13

C Signage in White Flint Complex Inadequate and Inconsistent 

While the agency has posted signage denoting exit routes, some of the 

signage does not meet Federal guidelines and industry standards. 

Specifically, current signage, including evacuation maps and stairwell 

routing in the White Flint complex, is inadequate and inconsistently 

designed and posted. These deficiencies exist because management was 

unfamiliar with applicable guidance and standards. Without upgrading 

existing signage to meet Federal guidance and industry standards, NRC 

staff in the White Flint complex may be unable to evacuate the complex 

safely and expediently during an emergency. 

Federal Regulations and Best Practice 

The Code of Federal Regulations states that if the route to an exit “is not 

immediately apparent, signs must be posted along the exit access 

indicating the direction of travel to the nearest exit....” It further states, 

“the line-of-sight to an exit sign must be clearly visible at all times.” These 

general requirements are supplemented by best practices for the design 

and deployment of floor maps and other visual aids, such as photo 

luminescent signage. For example, best practices suggested by floor map 

manufacturers state that evacuation maps should be photo luminescent 

(i.e., “glow-in-the-dark); be strategically placed; and include specific 

features such as primary and alternate evacuation routes, the location of 

emergency equipment (i.e., AEDs, first aid kits, and fire extinguishers), 

instructions for reporting an emergency (e.g., calling 911 and building 

address), and the assembly area location where occupants should gather 

after an evacuation. Additionally, a Department of State audit report on 

emergency preparedness recommended that exit routes should also be 

marked with photo luminescent tape at floor and eye level so that 

occupants can make out the exit route even if interior lighting is 

inoperable. 
Audit of NRC’s Occupant Emergency Program 

14

 

Examples of photo luminescent tape used in darkened areas denoting exit routes 

Headquarters Emergency Signage Inadequate 

Auditors inspected the White Flint complex and found that evacuation 

maps do not comply with Federal guidance. First, during a walkthrough of 

the White Flint complex, auditors noted that the maps are not posted on 7 

of 22 floors in One White Flint or 10 of 15 floors in Two White Flint. 

Second, auditors’ inspection of maps in the White Flint complex revealed 

that they lack many of the best practice features such as being photo 

luminescent, noting primary and secondary evacuation routes, and the 

location of emergency equipment, emergency reporting information, and 

assembly areas. 

 Photo showing a map in Photo showing a map in 

 One White Flint Two White Flint 
Audit of NRC’s Occupant Emergency Program 

15

Third, as illustrated in the photos above, neither map from the White Flint 

complex is adequately marked to use in emergencies. Lastly, the maps 

are not consistently placed in the same location on each floor in the White 

Flint complex. Essentially, in their current form, the diagrams function as 

floor maps rather than evacuation tools and are therefore not helpful for 

staff use during an emergency. 

In addition, exit routes in stairwells are not marked to indicate the direction 

of travel to the nearest exit. Further, stairways in the White Flint complex 

do not have photo luminescent tape at floor and eye levels to indicate the 

direction of travel in an emergency. 

NRC Management Unaware 

Auditors met with senior staff to present their observations, and learned 

that management was unaware of requirements for exit signs and was 

unfamiliar with best-practice guidance for emergency signage. Without 

awareness of these standards, agency management has no basis for 

judging the adequacy of existing exit and emergency signage in NRC 

headquarters buildings and making necessary upgrades.

Increased Risk to Building Occupants 

Auditors did not identify cases in which substandard exit and emergency 

signage at the White Flint complex had resulted in injury or loss of life. 

Nevertheless, non-compliance with Federal regulations and best-practice 

standards increases the risk that NRC employees, visitors, or other 

occupants of the White Flint complex will not be capable of safe and timely 

evacuation in the event of an emergency. This risk is present for common 

emergencies, such as fire, and is arguably higher for incidents such as a 

catastrophic terrorist attack. NRC could mitigate this risk and improve 

occupant safety at its White Flint complex with relatively minor investment 

in emergency signage upgrades to meet Federal requirements, and by 

incorporating best-practices that are becoming common among 

businesses and other Federal Government agencies. 

Recommendations

10. Update maps so they are compliant with industry best practices and 

can function as evacuation tools. 

11. Consistently place maps in the same location on every floor of the 

White Flint complex. 
Audit of NRC’s Occupant Emergency Program 

16

12. Post photo luminescent signs and markings at both eye and floor 

levels, along all exit accesses indicating the direction of travel to the 

nearest exit. 
Audit of NRC’s Occupant Emergency Program 

17

IV. CONSOLIDATED LIST OF RECOMMENDATIONS 

 OIG recommends that the Executive Director for Operations: 

1. Require annual training for those with responsibilities, such as floor 

and stair monitors, during an emergency. 

2. Require annual, unannounced, full-scale evacuation drills, including 

mustering and accountability assessments, at all headquarters and 

regional complexes. 

3. Provide employees with periodic guidance reinforcing key points of 

the agency’s occupant emergency plans and emergency procedures. 

4. Develop procedures for ensuring that AEDs are routinely maintained 

and checked for operability. 

5. Post contact information and, where necessary, a telephone in the 

immediate vicinity of all AED devices. 

6. Publicize the location of each AED (e.g., on the internal Web site or 

in the agency’s occupant emergency plan). 

7. Include information on the AED program in the agency’s occupant 

emergency plan. 

8. Develop procedures for consistently issuing PEKs. 

9. Develop procedures for properly maintaining PEKs. 

10. Update maps so they are compliant with industry best 

practices and can function as evacuation tools. 

11. Consistently place maps in the same location on every floor of the 

White Flint complex. 

12. Post photo luminescent signs and markings at both eye and floor 

levels, along all exit accesses indicating the direction of travel to the 

nearest exit. 
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V. AGENCY COMMENTS 

At the exit conference on January 26, 2009, agency management stated 

their agreement with the findings and recommendations in this report. 

However, management also wanted to provide written comments to 

provide further insight into the actions the agency is taking to improve the 

Occupant Emergency Program. Specifically, management wished to 

include agency actions that resulted from a lessons learned report 

pertaining to a June 25, 2008, medical event. The agency’s comments 

are provided in Appendix B of this report. 
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APPENDIX A 

SCOPE AND METHODOLOGY 

Auditors evaluated the extent to which NRC’s Occupant Emergency 

Program complies with Federal regulations and standards. This audit 

resulted from an FY 2008 audit, Audit of the Agency’s Continuity of 

Operations Plan, which was issued in FY 2008. 

The OIG audit team reviewed relevant Governmentwide criteria, including 

Federal requirements and standards governing the development and 

implementation of Occupant Emergency Plans as noted in the Code of 

Federal Regulations, Chapters 29 and 41, and the Federal Protective 

Services Occupant Emergency Plan guide. Auditors also reviewed 

agency-specific guidance, including Management Directives 10.122, 

Employee Assistance and Wellness Services Program, and 10.130, 

Safety and Health Program Under the Occupational Safety and Health 

Act. Independent reports pertaining to emergency preparedness were 

also consulted, including a Department of State audit report and a 

National Institute of Standards and Technology independent evaluation. 

Auditors randomly surveyed a total of 159 headquarters staff to determine 

their familiarity with their occupant emergency plan. Auditors also 

randomly inspected 139 PEKs located at headquarters to determine 

consistency in PEK contents and how they are maintained. The survey 

results were recorded on an OIG-created checklist, which was developed 

in accordance with Federal and agency requirements, standards, and best 

practices pertaining to emergency preparedness. Additionally, auditors 

inspected several pieces of emergency equipment located in headquarters 

buildings for placement and operability. These devices included AEDs, 

floor maps, and emergency lighting located in stairwells. Auditors 

analyzed the survey results to determine whether NRC is adequately 

maintaining emergency equipment. 

This work was conducted from June 2008 through October 2008 in 

accordance with generally accepted Government auditing standards. 

Those standards require that the audit is planned and performed with the 

objective of obtaining sufficient, appropriate evidence to provide a 

reasonable basis for any findings and conclusions based on the stated 

audit objectives. OIG believes that the evidence obtained provides a 

reasonable basis for the report findings and conclusions based on the 

audit objective. The audit work was conducted by Beth Serepca, Team 

Leader; Terri Cooper, Audit Manager; and Jaclyn Storch, Senior 

Management Analyst. 
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APPENDIX B 

AGENCY COMMENTS